Optimal Treatment Of Fractures Research Articles

Ballistic femoral neck fractures: Associated injuries and outcomes.

Ballistic fractures of the femoral neck, rare injuries that overwhelmingly affect younger adults, pose significant challenges to the treating surgeon. However, there is limited literature that the treating surgeon can leverage to guide their treatment decisions. The goal of this study is to describe the demographics, associated injuries, outcomes, and complications associated with ballistic femoral neck fractures. This retrospective case series, performed at a single, academic, urban, level-one trauma center, evaluated patients with a ballistic fracture of the femoral neck (AO/OTA 31B) between 2003 and 2022. International Classification of Disease codes were utilized to identify patients in the electronic medical record. Chart review was performed to assess patient demographics, associated injuries, success rate of operative and nonoperative intervention, and post-operative complication rate and types. Seventeen patients were included (94 % male; median age 22.5 years). Median follow up was 12.2 months (range 1-84 months). Five patients (29 %) sustained a concomitant vascular injury. Eight patients (47 %) sustained an additional osseous injury. The median injury severity score was 9 (interquartile range 4-17). Thirteen patients were treated with operative reduction and fixation, 3 patients with incomplete fractures were treated nonoperatively, and one was treated with acute total hip arthroplasty (THA). Overall, 12 of 17 patients (71 %) healed their fracture or had an uncomplicated recovery after acute THA. Of the 13 patients treated with operative reduction and fixation, 8 (62 %) healed their fracture and 5 (38 %) developed one or more post-operative complications. Nearly 1 in 3 patients with ballistic femoral neck fractures sustain concomitant vascular injury and almost half sustain another osseous injury. In this series, only 62 % of patients who underwent operative reduction and fixation healed their fractures, and nearly 40 % of patients treated with operative reduction and fixation developed a post-operative complication. Given the poor outcomes and high complication rates associated with these injuries, surgeons should counsel patients with ballistic femoral neck fractures accordingly. Further research into the optimal treatment of ballistic femoral neck fractures is needed.

The Clinical and Radiological Outcomes and Complications of Bilboquet Implant for Proximal Humerus Fractures: A Systematic Review.

Background/Objectives: There is no consensus in the literature regarding the optimal treatment for complex proximal humerus fractures (PHFs). The aim of this study is to evaluate the clinical, functional, and radiological outcomes, and complications, associated with the Bilboquet implant in the treatment of PHFs. Methods: The search was conducted from the first description of the Bilboquet device in 1994 to June 2024, across PubMed, Web of Science, and Google Scholar, using specific keywords such as ("Bilboquet" OR "Bilboquet prosthesis" OR "Bilboquet device") AND ("proximal humerus fracture" OR "shoulder fracture"), along with Boolean operators. The inclusion criteria comprised studies published in English or French that focused on the use of the Bilboquet implant for PHFs. Eligible study designs included case series, cohort studies, randomized controlled trials (RCTs), and non-RCTs evaluating clinical, functional, and radiological outcomes, and complications. Studies that do not contain relevant results to this systematic review, pediatric populations, or the use of alternative implants were excluded. Results: A total of eight studies (235 patients) published between 1996 and 2021 were included. The mean age was 68.6 years (56 to 76.8) in all the studies. The majority of patients, 76.2%, were females, with male patients accounting for only 23.8%. A total of 10 (4.3%) patients had 2-part fractures, 40% of patients had 3-part fractures, and 55.7% of patients had 4-part fractures. The mean follow-up was 36.4 months (25.8-88.7), with a mean constant score of 69.7 (62-78.6). Complications included non-union in 2.65% of cases, avascular necrosis in 19.7%, revision surgery in 5.1%, and protrusion of the staple in 4.3%. Conclusions: Despite limited knowledge of the Bilboquet implant, it shows promise in managing complex PHFs in both young and older adults, with favorable clinical and radiological outcomes. It offers advantages over traditional fixation methods and allows easy conversion to arthroplasty if osteonecrosis occurs. However, the long-term outcomes require further study. While early results are promising, larger randomized studies are needed to confirm its broader clinical utility.

Concurrent plate fixation and pedicled flap coverage for open fractures complicated by soft tissue loss of the tibia in pediatric cohort: a clinical series.

The optimal treatment of open fractures complicated by soft tissue loss of pediatric tibial fractures remains inconclusive. The author described a protocol of concurrent plate fixation and pedicled flap coverage and retrospectively reviewed the outcomes of such injuries. A total of 25 pediatric cases with Gustilo lllB open tibial fracture were treated by single-stage plate fixation and pedicled flap reconstruction. The reviewed information consisted of time to fix and flap, type of plate, type of pedicled flap, fracture union time, postoperative complication and the clinical outcomes by objective scoring system. Fix and flap was undergone between 7 and 12days after injury with the average time of 8.2days. Regarding the type of plate, narrow LCP was applied in 8, 3.5mm precontoured LCP in 10, 5.0mm precontoured in 2 and double LCP in 5. According to soft tissue reconstruction, the medial gastrocnemius flap was selected in 6 cases, myocutaneous medial gastrocnemius flap in 2, soleus flap in 3, hemisoleus flap in 5, reverse sural flap in 6 and combined medial gastrocnemius and hemisoleus flaps in 3. No flap-related complication was demonstrated. All cases established fracture union in between 12 and 24weeks with an average time to union of 17.7weeks. According to postoperative complications, infected plate occurred in 2 cases and implant irritation in 5. According to Puno functional score, excellent results were presented in 7 cases and good results in 18 cases. Single-stage plate fixation and pedicled flap coverage are a reliable regimen for pediatric open fractures complicated by soft tissue loss of the tibia.

Does Treatment of Adolescent Fractures Differ between Specialties? A Survey among Pediatric and Trauma Surgeons.

From a traumatological point of view, adolescents (12-18 years) represent a special group of patients. This is due to their biomechanical characteristics being between pediatric and adult fracture types. In Germany, they are treated by both pediatric and trauma surgeons. For this survey, seven cases of adolescent fractures were evaluated by both pediatric and trauma surgeons and their preferred treatment options were raised. The questionnaires were completed anonymously. Additionally, information on the specialty and years of experience were asked. In total, 126 valid questionnaires were obtained (from 78 pediatric and 48 trauma surgeons). The respondents' mean clinical experience was high (71.5% stated more than 10 years of surgical experience). For every single exemplary case, a significant difference in therapy decisions between the groups could be found. For the demonstrated seven cases, a tendency toward more operative and more invasive treatments was found with trauma surgeons compared to pediatric surgeons. On the other hand, there was a risk of underestimating the severity of fracture entities similar to adult fractures in pediatric surgeons. Overall, a continuous interdisciplinary exchange between both surgical specialties is necessary to ensure optimal treatment for adolescent fractures and to develop guidelines in the future.

Treatment of Syndesmotic Instability: The Importance of Malleolar Fixation

A significant proportion of syndesmotic injuries often occur simultaneously with malleolar fractures. The existing literature emphasizes that even slight misalignments in the malleolar structures can lead to altered talar motion, ultimately resulting in post-traumatic ankle arthritis. Rotational ankle fractures with syndesmotic injury can manifest with isolated or a combination of lateral, medial, and/or posterior malleolar fractures, and an accurate anatomic restoration of malleolar fractures has been emphasized. One such reason for anatomic reduction is that the fracture fragment may have an important attachment site for ligaments that contributes to the stability of the ankle and syndesmotic joints. While the biomechanical impact of malreduction of the lateral and medial malleolus osteoligamentous complex has been well documented and understood, controversy persists regarding the optimal surgical treatment of posterior malleolar fractures in the context of syndesmosis instability. Advanced imaging and biomechanical studies have shed new light on the role of the posterior malleolus in syndesmosis stability, suggesting that anatomic reduction of the posterior malleolar fragment could decrease the necessity of transfixation of the syndesmosis, lowering the risk of malreduction. As a result, there is growing advocacy for anatomically reducing and fixing the posterior malleolus in ankle fractures with syndesmotic injuries. This review focuses on the critical role of malleolar fixation in the management of syndesmotic injuries. Level of Evidence : Diagnostic Level V—expert opinion. See Instructions for Authors for a complete description of levels of evidence.

Surgical versus conservative treatment for odontoid fractures in older people: an international prospective comparative study.

The optimal treatment for odontoid fractures in older people remains debated. Odontoid fractures are increasingly relevant to clinical practice due to ageing of the population. An international prospective comparative study was conducted in fifteen European centres, involving patients aged ≥55years with type II/III odontoid fractures. The surgeon and patient jointly decided on the applied treatment. Surgical and conservative treatments were compared. Primary outcomes were Neck Disability Index (NDI) improvement, fracture union and stability at 52weeks. Secondary outcomes were Visual Analogue Scale neck pain, Likert patient-perceived recovery and EuroQol-5D-3L at 52weeks. Subgroup analyses considered age, type II and displaced fractures. Multivariable regression analyses adjusted for age, gender and fracture characteristics. The study included 276 patients, of which 144 (52%) were treated surgically and 132 (48%) conservatively (mean (SD) age 77.3 (9.1) vs. 76.6 (9.7), P = 0.56). NDI improvement was largely similar between surgical and conservative treatments (mean (SE) -11 (2.4) vs. -14 (1.8), P = 0.08), as were union (86% vs. 78%, aOR 2.3, 95% CI 0.97-5.7) and stability (99% vs. 98%, aOR NA). NDI improvement did not differ between patients with union and persistent non-union (mean (SE) -13 (2.0) vs. -12 (2.8), P = 0.78). There was no difference for any of the secondary outcomes or subgroups. Clinical outcome and fracture healing at 52weeks were similar between treatments. Clinical outcome and fracture union were not associated. Treatments should prioritize favourable clinical over radiological outcomes.

Changing treatment of hip fractures in Finland

IntroductionHip fracture treatment should be as standardized and effective as possible, with emphasis on fast recovery and avoidance of complications, especially those leading to reoperations. There is accumulating evidence regarding the optimal treatment of hip fractures but reports of whether this has influenced treatment in the clinical setting are sparse. The objective of this study was to determine the trends of hip fracture incidence and treatment in Finland, with special regard to how we treat older patients compared to younger ones.Materials and methodsAll operatively treated hip fractures in Finland between 1997 and 2018 were identified from a national administrative register. The incidence of these fractures and operations performed to treat them were calculated based on the adult population size.ResultsApart from a decline in the elderly age groups during the first half of the study period, the incidence of hip fractures remained relatively constant. However, the incidences of different operations changed significantly. In treatment of femoral neck fractures from 1997 to 2018, the incidence of cemented hemiarthroplasty (HA) increased from 41.1 to 59.9 per 100,000 person-years (105) and hybrid total hip arthroplasty (THA) from 0.56 to 5.93 per 105, while the incidence of internal fixation (IF) decreased, for instance screw fixation from 12.5 to 2.7 per 105. The incidence of cementless HA decreased from 13.3 to 1.2 per 105. These changes were much more pronounced in the elderly population and there was a statistically significant difference in the proportion of patients aged > 59 treated with cemented HA and IF in 1997 compared to 2018. For trochanteric and subtrochanteric fractures, treatment with intramedullary nails replaced extramedullary devices as the most common treatment method.ConclusionsThe changes in treatment methods in Finland correspond to the increasing knowledge available about the optimal treatment of hip fractures and global treatment trends.

Outcome of Internal Fixation by Cephalomedullary Nail versus Outcome of Bipolar Hemiarthroplasty in the Treatment of Unstable Pertrochanteric Femoral Fractures in Elderly: Systematic Review and Meta-analysis

Abstract Background Pertrochanteric femoral fractures are extracapsular metaphyseal fractures of proximal femur that involve the region between the femoral neck and shaft. Intertrochanteric femur fractures, the most common type of fragility fractures in the elderly, account for 55% of proximal femoral fractures. Intertrochanteric femur fractures have high fatality and disability rates, resulting in a huge burden on the economy and on society. Objective To compare the advantages and disadvantages of the PFN and BHA to provide reliable evidence for clinicians in selecting the optimal treatment for unstable pertrochanteric fractures. Patients and Methods This systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2022. Data Extraction Data were independently extracted by two reviewers and cross-checked. Results This study included 12 samples which recruited 1019 patients with unstable intertrochanteric fractures, form which 515 patients underwent bipolar hemiarthroplasty (BHA) and 504 patients underwent proximal femoral nail (PFN). No significant difference between BHA and PFN in operative time and post-operative hospital stay was found. Intra-operative blood loss and incidence of blood transfusion was higher in BHA compared with PFN. HHS was higher after PFN than after BHA. Patients underwent PFN required larger period for partial weight bearing compared with who underwent BHA. There were no statistically significant difference between both groups regarding postoperative mobility scores, reoperation rate, incidence of infection and limb length alteration. The overall mortality rate risk ratio revealed that the incidence of mortality was higher after BHA than PFN. Conclusion Both PFN and BHA can be used in managing fractures of the Intertrochanteric in elderly patients. PFN establishes itself as a better modality than BHA due to lower postoperative mortality and better functional outcomes. BHA should ideally be reserved for lower life expectancies and those requiring immediate weight bearing patients.

Outcome of Flexible Intramedullary Nailing versus Plating in Treatment of Diaphyseal Femur Fractures in Paediatrics: Systematic Review and Meta-analysis

Abstract Background Pediatric femoral fractures are the most the common long bone fracture in children, with one third of these occurring between ages 5 to 12. These injuries are usually the result of road traffic accidents, sports and non-accidental injury. Different modalities exist for managing these fractures, often stratified according to the age of the patient. Aim of the Work The aim of this work is to provide a complete overview of the optimal surgical treatment of diaphyseal femur fractures in children by evaluating and comparing the clinical and functional outcomes of flexible intramedullary nailing versus plating for such fractures. Patients and Methods This review followed the Cochrane Handbook's standard methodology and reported the findings in accordance with the Preferred Reporting Items for Systematic Reviews and Meta- analyses (PRISMA) statement guidelines. Result In patients undergoing flexible nailing, the surgical variable data found this treatment modality to be superior in terms of certain operative features: shorter operative duration times (p = 0.00001), smaller volumes of estimated blood loss (p = 0.00001). There was no difference regarding length of hostital stay (p = 0.59). This suggests that flexible nailing may offer increased safety to patients in terms of duration of anesthesia, volume of blood loss, and cost of surgery when compared to plating. However, Secondary outcome analysis also found a statistically significant increased risk of malunion (p = 0.002) and metalwork irritation (p = 0.00001) when using FIN compared to plating techniques. There was no difference regarding risk of infection (p = 0.53) and developing leg length discrepancy (p = 0.44). Conclusion Options for stabilization and fixation in this age group include flexible nailing, plating (open or sub-muscular), external fixation, or hybrid techniques.

Management of Open Fractures of the Extremities and Pediatrics.

The modern management of open fractures was established after the foundational work of Gustilo and Anderson, but we continue to strive to determine the optimal treatment of open fractures to diminish the risk of infection. The ideal timing of antibiotics, presentation to the operating room, and timing of procedures such as flap coverage continue to be investigated with incremental changes recommended over the years. This article aims to provide the most recent review of the literature regarding the timing and management of both upper and lower extremity open fractures, pediatric open fractures, current topics of controversy, and the data supporting current treatment recommendations.

Factors Associated With Adverse Radiographic Outcomes Following Operative Management of Ankle Fractures: A Single-Center Study.

Introduction Ankle fractures arecommonly encountered fractures in emergency departments worldwide. These fractures often have significant articular involvement that requires anatomic surgical reduction and stabilization. Radiographs can be used in everyday practice to evaluate ankle fractures utilizing various parameters to assess reduction quality intraoperatively and postoperatively. Several factors have been found to influence the reduction quality of fractures across body regions.This retrospective study aimed to evaluate the influence of several factors on the reduction quality of ankle fractures in a tertiary care center in the Kingdom of Bahrain. Materials and methods A total of 462 records were identified during the search, and 68 records were excluded. A total of 394 ankle fractures met the inclusion criteria for the study. Five orthopedic surgeons then evaluated the operative films in accordance with the Delphi consensus parameters for evaluating ankle fractures, and the reductions were graded as good, adequate, or poor. Results The study included 394 ankle fractures that met the inclusion criteria, and four significant associations were notedto affect the quality of reduction. Ankle fractures with posterior malleolus involvement (PMI) were significantly associated (p = 0.001) with fragments smaller than 15% and larger than 20% having decreased outcomes. The number of daysfrom admission to operation was also significant (p = 0.009), with the best reductions observed between zero and one day from admission. Operating surgeon was also a significant factor (p = 0.038), with inferior reductions noted in specialist surgeons compared to trainees. The last significant association was the number of malleoli (p = 0.001), with an inferior reduction with a larger number of malleoli involved. Conclusion Ankle fractures are a common and significant orthopedic injury. Reduction quality is important for optimal outcomes after surgical stabilization. Various factors including the number of malleoli, the grade of the operating surgeon, and the time of surgery were significantly related to the quality reduction in this single-center study. Expedited surgical management of fractures that are amenable to early fixation, careful assessment, and meticulous technique in fixation offractures with multiple fractured malleoli is indicated to reduce the chance of malreduction particularly in complex injuries.Further assessment of factors related to reduction quality with large-scale prospective studies would provide orthopedicsurgeons with insights into the identification and optimal treatment of such fractures.

Developing a core outcome set for acetabular fractures: a systematic review protocol

BackgroundClinical trials investigating acetabular fractures are heterogeneous in their investigated outcomes and their corresponding measurements. Standardization may facilitate comparability and pooling of research results, which would lead to an increase in knowledge about the optimal treatment of acetabular fractures, resulting in long-term evidence-based treatment decisions and improvements in patient care. The aim of this systematic review is to identify the reported outcomes and their measurements from studies on treatments for acetabular fractures to develop a core outcome set which contains the most relevant outcome measures to be included in future studies.MethodsStudies published in English and German including patients aged 16 years and older, with a surgically treated acetabular fracture, will be included. Studies with nonsurgical treatment, pathologic fractures, polytraumatized patients, and patients younger than 16 years of age will be excluded because other outcomes may be of interest in these cases. Any prospective and retrospective study will be included. Systematic reviews will be excluded, but their included studies will be screened for eligibility. The literature will be searched on MEDLINE, CENTRAL, Web of Science, ClinicalTrials.gov, and WHO ICTRP. Risk of selective reporting of outcomes will be assessed using the Outcome Reporting Bias in Trials classification system. Heterogeneously defined outcomes that measure the same outcome will be grouped and subsequently categorized into outcome domains using the taxonomy of the Core Outcome Measures in Effectiveness Trials Initiative.DiscussionIt is expected that a high number of studies will be included, and many outcomes will be identified using different definitions and measurement instruments. A limitation of this systematic review is that only previously investigated outcomes will be detected, thus disregarding potentially relevant outcomes.Systematic review registrationPROSPERO CRD42022357644

Reverse Shoulder Prosthesis for Proximal Humeral Fractures: Primary Treatment vs. Salvage Procedure.

Background: The optimal treatment for complex proximal humerus fractures (PHFs) lacks consensus, with reverse total shoulder arthroplasty (RTSA) often being a final resort rather than a primary approach. This study aimed to compare outcomes and satisfaction rates of primary RTSA for PHFs versus salvage RTSA for previously unsuccessful treatments. We hypothesized that primary RTSA would yield superior clinical outcomes, functional scores, and patient satisfaction. Methods: A retrospective analysis of RSA procedures between 2011 and 2021 was conducted, focusing on primary RTSA for PHFs or salvage RTSA for failed osteosynthesis. Patients meeting inclusion criteria underwent clinical and radiological follow-up for at least two years. Demographic characteristics, outcomes scores, and range of motion (ROM) were assessed. Results: Of 63 patients, 42 underwent primary RTSA and 21 underwent salvage RTSA. The median follow-up was 50 months. Statistically significant differences favored primary RTSA in forward flexion, abduction, internal rotation, and Constant shoulder score. Patient satisfaction levels did not significantly differ between groups. Complications occurred in 7.15% of primary RTSA cases and 14.28% of salvage RTSA cases. Conclusions: Primary RTSA may yield slightly better outcomes and lower complication rates compared to salvage RTSA. Further prospective studies are necessary to validate these findings.

Stress Fractures of the Lower Limb in Military Personnel (Literature Review)

Summary. Stress fractures are a common pathology among military personnel, occurring with a frequency of 1.5% to 31%, depending on the studied contingents. Fractures of the lower limbs occur more often, leading to impaired function and a long-term decrease in working capacity, which determines the medical, social, and economic significance of the problem. The issues of timely diagnosis and optimal treatment of stress fractures of the lower extremities in order to minimize the time of return to military service remain undefined. Objective: an analysis of the literature devoted to stress fractures of the lower limb in military personnel. Material and Methods. A search in PubMed databases from 1952 to 2023 using the search strategy “stress fractures in militaries” was conducted. Results. 671 publications were found and a significant increase in their number (249) over the past 7 years was noted; meta-analyses were 4 and randomized controlled studies were 28. Other publications belong to III and IV levels of evidence. Among all publications, only 401 were related to stress fractures of the lower extremities in military personnel. Conclusions. Stress fractures occur when increased and repeated load is applied to normal bone, which leads to microdamages and fractures. The etiology of stress fractures is multifactorial. The main complaints are localized pain with or without swelling and tenderness on palpation, aggravated by physical exertion. Early diagnosis is critical and is based on a careful history, orthopedic examination, and evaluation of appropriate imaging modalities. Classification of stress fractures based on type, location, and risk is important for determining treatment strategy. The analysis of the literature indicates a lack of protocols for the treatment and prevention of stress fractures of the lower extremities in military personnel. However, modern literature in this area is mostly of low quality and consists of studies of a small sample. This necessitates further research, especially in terms of prevention and surgical treatment.

The cadaveric research model for calcaneus fractures: A scoping review of biomechanical, anatomical, radiographic and fracture fixation studies

BACKGROUNDCalcaneal fractures remain a big challenge in orthopaedic surgery and lead to long lasting disabilities. Cadaveric research plays an important role in determining optimal fracture treatment. This scoping review aims to provide insight into cadaveric research that has been conducted on calcaneal fractures, including biomechanics, fixation, approaches and radiographic studies. METHODOLOGYA search strategy was created and implemented as per PRISMA guidance. 3 databases, Medline, Embase and Scopus, were used when conducting this review. Results484 individual studies were retrieved across the 3 databases, of which 186 duplicates were excluded. Study abstracts were individually reviewed, of which 208 studies were excluded in accordance with study criteria. 90 papers were sought for retrieval, of which 83 full text papers were successfully retrieved. Of the full papers retrieved, 22 did not meet our inclusion criteria, and 19 papers related only to talus fractures. In the end, 43 cadaveric studies pertaining to this scoping review were included and reviewed. DiscussionStudies were grouped into biomechanical, anatomical, fixation and radiographic studies for review. ConclusionEvaluation of current cadaveric studies pertaining to calcaneal fractures has allowed greater insight into the myriad challenges in the management of these injuries. Effects of intra-articular fractures on calcaneal biomechanics assist in establishing surgical goals. Whilst fixation studies showing good stability of nail fixations could encourage further development in minimally invasive techniques. Avoiding pitfalls seen in the extensile lateral approach. Recommendations of areas for further research include use of external fixators, fixation in non-Sanders Type 2 fractures, and comparison of intraoperative CT/3D fluoroscopy with o conventional fluoroscopy.

Let's Agree to Disagree on Operative Versus Nonoperative Treatment for Distal Radius Fractures in Older People: Protocol for a Prospective International Multicenter Cohort Study.

Distal radius fractures are the most frequently encountered fractures in Western societies, typically affecting patients aged 50 years and older. Although this is a common injury, the best treatment for these fractures in older patients is still under debate. This prospective study aims to compare the outcome of operatively and nonoperatively treated distal radius fractures in the older population. Only patients with distal radius fractures for which equipoise regarding the optimal treatment exists will be included. This prospective international multicenter observational cohort study will be designed as a natural experiment. Natural experiments are observational studies in which treatment allocation is determined by factors outside the control of the investigators but also (largely) independent of patient characteristics. Patients aged 65 years and older with an acute distal radius fracture will be considered for inclusion. Treatment allocation (operative vs nonoperative) will be based on the local preferences of the treating hospital either in Switzerland or the Netherlands. Hence, the process governing treatment allocation resembles that of randomization. Patients will be identified after treatment has been initiated. Based on the radiographs and baseline information of the patient, an expert panel of 6 certified trauma surgeons from 2 regions will provide their treatment recommendation. Only patients for whom the experts disagree on treatment recommendations will ultimately be included in the study (ie, for whom there is a clinical equipoise). For these patients, both operative and nonoperative treatment of distal radius fractures are viable, and treatment choice is predominantly determined by personal or local preference. The primary outcome will be the Patient-Rated Wrist Evaluation score at 12 weeks. Secondary outcomes will include the Physical Activity Score for the Elderly, the EQ questionnaire, pain, the living situation, range of motion, complications, and radiological outcomes. By including outcomes such as living situation and the Physical Activity Score for the Elderly, which are not relevant for younger cohorts, valuable information to tailor treatment to the needs of the older population can be gained. According to the sample size collection, which was based on the minimal important clinical difference of the Patient-Rated Wrist Evaluation, 92 patients will have to be included, with at least 46 patients in each treatment group. Enrollment began in July 2023 and is expected to continue until summer 2024. The final follow-up will be 2 years after the last patient is included. Although many trials on this topic have previously been published, there remains an ongoing debate regarding the optimal treatment for distal radius fractures in older patients. This observational study, which will use a fairly new methodological study design, will provide further information on treatment outcomes for older patients with distal radius fractures for which to date equipoise exists regarding the optimal treatment. DERR1-10.2196/52917.

PATELLA FRACTURES IN THE FRAIL HOST: A SYSTEMATIC REVIEW

AbstractObjectivesThe outcomes from patella fracture have remained dissatisfactory despite advances in treatment, especially from operative fixation1. Frequently, reoperation is required following open reduction and internal fixation (ORIF) of the patella due to prominent hardware since the standard technique for patella ORIF is tension band wiring (TBW) which inevitably leaves a bulky knot and irritates soft tissue given the patella's superficial position2. We performed a systematic review to determine the optimal treatment of patella fractures in the poor host.MethodsThree databases (EMBASE/Medline, ProQuest and PubMed) and one register (Cochrane CENTRAL) were searched. 476 records were identified and duplicates removed. 88 records progressed to abstract screening and 73 were excluded. Following review of complete references, 8 studies were deemed eligibleResultsComplication rates were shown to be high in our systematic review. Over one-fifth of patients require re-operation, predominantly for removal of symptomatic for failed hardware. Average infection rate was 11.95% which is higher than rates reported in the literature for better hosts. Nevertheless, reported mortality was low at 0.8% and thromboembolic events only occurred in 2% of patients. Average range of movement achieved following operative fixation was approximately 124 degrees. Upon further literature review, novel non-operative treatment options have shown acceptable results in low-demand patients, including abandoning weight-bearing restrictions altogether and non-operatively treating patients with fracture gaps greater than 1cm. Regarding operative management, suture/cable TBW has been investigated as a viable option with good results in recent years since the materials used show comparable biomechanics to stainless steel. Additionally, ORIF with locking plates have shown favourable results and have enabled aggressive post-operative rehabilitation protocols. TBW with metallic implants has shown higher complication rates, especially for anterior knee pain, reoperation and poor functional outcomes.ConclusionThere is sparse literature regarding patella fracture in the poor host. Nevertheless, it is clear that ORIF produces better outcomes than conservative treatment but the optimal technique for patella ORIF remains unclear. TBW with metallic implants should not remain the standard technique for ORIF; low-profile plates of suture TBW are more attractive solutions. Non-operative treatment may be considered for low-demand individuals however any form of patellectomy should be avoided if possible.Declaration of Interest(b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

The Moderating Effect of Age on Patient-Reported Benefits From Operative Management of Intra-Articular Distal Radius Fractures: A Meta-Regression Analysis

The optimal treatment of intra-articular distal radius fractures in older adults (>65 years) remains uncertain despite numerous randomized trials. The purpose of this study was to examine the moderating effect of age on patient-reported benefits of volar locked plating versus cast immobilization for intra-articular distal radius fractures. A meta-analysis of randomized controlled trials was conducted to compare volar locked plating and cast immobilization of intra-articular distal radius fractures. Meta-regression analyses were used to examine the moderating effect of age on improvements in patient-reported outcome measures from operative treatment of distal radius factures. Modeling results were then used to estimate improvements in Disability of the Arm, Shoulder, and Hand (DASH) scores from surgery that are associated with ages ranging from 65 to 90 years. Twelve randomized controlled trials including 1,806 patients were included. Age was a significant moderator of patient-reported benefits after operative treatment, with decreasing DASH score benefits from surgery associated with older ages. Model predictions show that a majority of patients aged <70 years will experience a clinically meaningful improvement in DASH scores from surgery. Patients aged 70-80 years have decreasing DASH benefits with age, but many may still experience a clinically meaningful improvement from surgery. Patients aged >80 years are unlikely to experience a clinically meaningful improvement in DASH scores with surgical management. Older ages are associated with decreased benefits from surgical management with volar locked plating as compared to cast immobilization. Patients aged >80 years are unlikely to experience a clinically significant improvement with surgery. Surgeons and policymakers may use these data to counsel patients, health systems, and professional organizations on the risks and benefits of operative treatment in older adults. Prognosis 1, Meta-Analysis of Randomized Controlled Trials.

Comparison of reconstruction nails versus dual implants in the treatment of ipsilateral femoral neck and shaft fractures in adults: a meta-analysis and systematic review

ObjectiveThere is no consensus on the optimal treatment for ipsilateral femoral neck and shaft fractures. This meta-analysis aims to assess the effectiveness of reconstruction nails and dual implants in treating ipsilateral femoral neck and shaft fractures to provide a basis for decision-making when selecting the optimal approach.MethodsRelevant articles were retrieved from Pubmed, Embase, and Cochrane databases using the keywords "neck of femur", "shaft" and "fracture fixation" from inception until November 17, 2022. The screening process of the studies was conducted independently by two assessors, who assessed each study's eligibility and two assessors assessed the quality. Then compared differences in outcome measures using RevMan 5.3 software.ResultsA total of ten retrospective cohort studies were included. There were no significant differences in union time, union rate, union-related complications (malunion, nonunion, delayed union) of femoral neck and shaft fractures, osteonecrosis of the femoral head, and functional outcomes (Friedman-Wyman scoring system) (P > 0.05).ConclusionOur pooled estimates indicated that reconstruction nails and dual implants for ipsilateral femoral neck and shaft fractures could yield satisfactory surgical results, and that there is no difference between the two treatment methods.Trial registrationThis meta-analysis was registered on the PROSPERO website (registration number: CRD42022379606).

Surgical options for distal radius fractures of type C in elderly patients over 65 years old: a comparison of external fixation with Kirschner wires and volar locking plate

Backgroundue to the lack of consensus on the optimal surgical treatment for distal radius fractures (DRF) in elderly patients over 65 years old, the purpose of this study was to compare the efficacy of external fixation (EF) with Kirschner wires and volar locking plate (VLP) in the treatment of DRF through a retrospective cohort study. We hypothesized that there would be no significant difference in overall complications and functional recovery between the two methods.MethodsWe retrospectively analyzed 62 patients over 65 years old who underwent surgical treatment for C-type DRF between 2019 and 2022. Based on the different treatment methods, they were divided into the EF group and the VLP group. General data, inpatient data, and postoperative complications during follow-up were recorded. The X-ray images before surgery, after surgery, and at the last follow-up were analyzed, and the results of wrist motion range, Gartland–Werley wrist joint score, and DASH score were evaluated 6 months after surgery for both groups.ResultThirty patients underwent closed reduction and external fixation combined with Kirschner wire fixation, while 32 underwent open reduction and VLP fixation. The EF group had significantly shorter operation time, intraoperative blood loss, injury-to-surgery time, and hospital stay compared to the VLP group (all p < 0.001). At the last follow-up, the radiographic parameters (ulnar variance and radial inclination) and wrist joint function (wrist dorsiflexion and forearm supination) were better in the VLP group than in the EF group (p = 0.04, p = 0.01, p = 0.001, p = 0.02, respectively). However, there was no significant difference in overall Gartland-Werley wrist joint score, DASH score, and incidence of postoperative complications between the two groups (p = 0.31, p = 0.25, p = 0.47, respectively).ConclusionFor patients aged 65 and above with distal radius fractures (DRF) of type C, VLP and external fixation with Kirschner wires yield comparable functional outcome and complications rate at the short term. However, VLP allowed restoration of better radiological parameters.